A Psychiatrist’s Guide to Advocacy

November 2020

BOOK REVIEWS: A Psychiatrist’s Guide to Advocacy

Nov
2020
Vol. 32. No. 4
Richard Balon, MD

Departments of Psychiatry and Behavioral Neurosciences and Anesthesiology
Wayne State University School of Medicine
Detroit, Michigan, USA

Many physicians do not want to get actively involved in advocacy. Some may even ask what advocacy is. Yet they do not realize how important their advocacy for patient issues could be and that advocacy is “a ubiquitous part of physicians’ daily work” (p 4). We are frequently advocating for our patients without much thought about it as “advocacy.” So how do we define advocacy? “Applied specifically to health care, advocacy can be defined as the public voicing of support for causes, policies, or opinions that advance patient and population health” (p 4).

Psychiatry is in great need of advocacy for various patient- and discipline-related issues, because it “is arguably the most controversial specialty in the house of medicine” (p 6). There are a lot of negative and, at times, outright hostile perceptions of psychiatry in our society. “There is no ‘anti-pediatrics’ or ‘antinephrology’ movement, but there is an active and vocal anti-psychiatry movement. Chemotherapy, which has both lifesaving properties and potentially severe side effects, is not generally considered to be a barbaric and unnecessary treatment, but electroconvulsive therapy, which also has lifesaving properties and potentially severe side effects, sometimes is” (p 6). Interestingly, the American Medical Association recognizes advocacy “as a fundamental responsibility of physicians” (p 11-12). Yet, medical training, including for medical students and residents, “is not known for producing advocates” (p 9). In addition, “compared with some other medical specialties, psychiatry has a less robust tradition of advocacy teaching and lags behind in terms of advocacy engagement and effectiveness” (p 12).

Understanding the imperative need for better and more advocacy in psychiatry at many levels, Drs. Vance, Kennedy, Weichers, and Levin put together this edited volume. The book consists of 3 parts: I. Understanding Advocacy (4 chapters); II. Practicing Advocacy (6 chapters); and III. Advocacy for Special Populations (10 chapters). Several chapters also end with short interviews with advocacy role models.

The 4 chapters of Part I explain what advocacy is and why it is important; conceptualize advocacy; discuss where we fit in advocating for our patients and for our profession; and provide guidance on how one becomes an advocate. The first chapter discusses issues such as levels of advocacy (patient-level, organizational-level, population-level); usable theories of advocacy (eg, power politics or power elites theory and tactical theories such as diffusion theory); factors in effective advocacy (collaborative and communication skills, knowledge of the issue, time); ethical considerations; and whether advocacy should be promoted as a specialization in medicine. The second chapter discusses 5 systemic health care system issues that challenge psychiatrists and patients, followed by 4 key elements of medically necessary medical care. The major systemic challenges include the lack of access to safe, effective health care covered by payees; an impending psychiatry workforce shortage; the lack of parity of mental health care; stigma against patients with and providers of treatment for mental disorders, including substance use disorders; and high rates of physician burnout. I liked the thorough discussion focused on what should be discussed with legislators regarding the differences between psychiatrists and psychologists, including the dangers of psychologists prescribing. The chapter ends with a table summarizing examples of advocacy across all levels to address major systemic issues in psychiatry.

The last chapter of Part I provides useful instructions on how to become an effective advocate, such as remaining up-to-date in one’s area of advocacy, awareness of sociopolitical contexts, and communication skills, including active listening, nonverbal cues, and conveying one’s message. Readers are reminded that the words and phrases one chooses for his/ her message are very important. To be an effective advocate, one has to know who the stakeholders are, what progress has or has not been made on the issue, who or what is involved in addressing or contributing to the issue, and what may be the best way to disseminate the message. The key aspects that should be addressed in an effective message are one’s key audience, key message, talking points, and story. The text suggests that advocacy should be integrated into one’s professional life.

Part II includes 6 chapters addressing patient-level advocacy, organizational advocacy, legislative advocacy, education as advocacy, research as advocacy, and engaging the popular media. I liked the chapter addressing legislative advocacy, with advice on how to build an effective strategy for policy development. The authors remind us that, “The adage ‘all politics is local’ should be amended to ‘all politics is relationship.’ Developing a relationship with your state and/or local legislators will put you in a better position to educate them about current mental health care issues, such as parity, scope of practice, and access to care” (p 127). We are reminded that “a well-informed legislator will be better equipped to block a potentially harmful bill” (p 127). I found useful the following practical tips on meeting with a legislator and/or an aide: expect the meeting to be brief (prepare a succinct 3-minute synopsis and anticipate questions); dress and behave professionally; provide a single “leave-behind” synopsis page; be sure to include an “ask” at every encounter with a legislator; and write a “thank-you” note within 24 hours. This chapter also includes a good table that summarizes the common types of written communications used in legislative advocacy, listing their purpose, core elements, and ways to spark interest and define your “ask.”

The chapter on education as advocacy proposes that residency programs should include didactic and experiential components into their training. The following chapter on research advocacy states, “Ultimately, how new evidence is or is not used lies outside the realm of research. Therefore, using research as advocacy requires translating scientific data into actionable knowledge so that the rest of society may act on the best available information” (p 170). Finally, the chapter on engaging the popular media includes great tips for connecting with the general audience (eg, avoid “turgid” prose, be thoughtful about the words used to frame issues; be attentive to the negative implicit bias and general misunderstanding of psychiatry; include stories as much as possible; use shorter sentences; and be clear and concise) and a table with tips from several books on writing.

In 10 chapters, Part III outlines advocacy for special populations, including children and families; older adults; LGBTQ patients; immigrants, refugees and their families; people with substance use disorders; military service members; veterans and their families; patients in medical settings; people with mental illness who are at risk for criminal justice involvement; and community and public sector advocacy.

This volume is the first of its kind. It is a real call for all of psychiatry to become engaged in advocacy for our patients and our profession. It is informative and exhaustive in details. It will be appreciated by any psychiatrist interested in getting involved in advocacy. 

CORRESPONDENCE

Richard Balon, MD
Wayne State University
Detroit, Michigan, USA

REFERENCES

Edited by Mary C. Vance, Katherine G. Kennedy, Ilse R. Wiechers, and Saul M. Levin; Washington, DC; American Psychiatric Association Publishing; 2020; ISBN 978-1-61537-233-1; pp 440; $59 (paperback).